Looking Ahead: The DOM in 2017

Well, whatever your political preferences, you have to admit that 2016 was an odd and disconcerting year.

For our department, though, it was an exceptional year, and 2017 promises to be even better. That’s not to say that there aren’t some storm clouds on the horizon, and some difficult choices that we’ll need to make. But we are well positioned to thrive and to lead.

Here is my take on the major issues facing the DOM, including some of our biggest opportunities and challenges. I’ll begin with issues specific to each of the sites, and then end with a few crosscutting issues and themes.

UCSF Health

 

As with all of our clinical sites, it is too early to predict the impact of the election on UCSF Health and our faculty and staff who are based there (Parnassus, MZ, Mission Bay). It’s a good bet that the shift toward value-based payments and population health will endure – these trends have been gathering momentum for 15 years, under administrations both Red and Blue, and they seem unlikely to go away. The more tangible threat will be to the millions of people who gained health insurance under the ACA.

For our department, the key imperative continues to be providing the highest value care (quality, safety, access, equity, patient experience, efficiency), and to build our competencies in population health. We must do this to remain competitive in the marketplace, generate the resources we need, and do right by our patients and partners. The efforts over the past several years in Lean, unit-based leadership teams, clinical information systems, patient safety, and quality improvement are bearing fruit, though there is much more to do.

Despite all this work, we remain an extremely expensive place to receive care. Some of the reasons for this are out of our control, but not all of them. Having just finished two weeks on the wards at Parnassus, I was again struck by the importance of communication (particularly between the primary teams and consultants) – it is often the case that a two-minute conversation between the ward and subspecialty team is all it takes to crack a tough case. This is an area I’d like us to focus on in the coming year – we should be able to do better, both to improve value and education.

As UCSF Health strives to provide high value care to all our patients (and the many patients who want to see us but can’t get in), it’s increasingly clear that we will depend on partnerships with community-based systems and providers. Last year, we established or deepened our relationships with John Muir, One Medical, and many smaller groups. This year, we need to figure out how these doctors relate to their colleagues in our department – not just in terms of faculty titles, but also in terms of communication and culture. It’s not a simple question, but it’s important that we get it right.

We are down to final interviews for the new position of Vice Chair for Clinical Affairs and Value Improvement; I should be able to announce my choice soon. This individual will be (along with Andy Gross, Associate Chair for Ambulatory Care and Population Health) my key partner in tackling these issues.

ZSFG

The County has had a good run, both clinically and financially, and has benefited from Neil Powe’s strong leadership. It has built its capacity in improvement, becoming a national leader among safety net hospitals in its use of Lean. The ACA has been very positive for ZSFG, since many patients who previously lacked health insurance now have MediCal. While an uptick in MediCal has hurt the bottom line at UCSF Health (we lose about 40 cents on the dollar for each patient), at ZSFG it has produced a new revenue flow that we’ve used to support programs there. Of course, the potential repeal of the ACA threatens this flow.

The decision by the City and County not to install UCSF Health’s version of Epic (Apex) was disappointing, in that it would have promoted collaboration between the two sites and made life easier for the many trainees and faculty who work at both UCSF Health and ZSFG. The Department of Public Health will choose an IT system for ZSFG (and its entire health system) soon – it’s still possible that it will be Epic, which would promote data sharing for both clinical and research purposes.

The plans for the new research building at ZSFG, on the current outdoor parking lot, are coming along well. This building, which still awaits approval by the Supervisors, will be a tremendous asset for basic and clinical research at the General, and will be funded entirely by UCSF. I urge you to make your feelings known about it to the Board of Supervisors at, or in advance of, their upcoming hearings on the matter in late January.

The VA

 

As a federal department, the VA is probably the UCSF partner most vulnerable to changes in Washington. As you know, there is a wing of the Republican Party that favors dismantling or markedly shrinking the VA system, instead giving veterans vouchers for care in the private sector. Such a change would be highly problematic: the VA has developed a number of unique programs and competencies that have served veterans well. Moreover, the linkage of VAs to academic health systems like UCSF has raised the quality of care for veterans. It is too early to know which way this one will go, but the veterans’ lobby is one of the most powerful in Washington and has traditionally fought for the current model.

There is also some uncertainty about the SF VA’s research enterprise, specifically where to put a research building to replace the current antiquated facilities. A Mission Bay location would have great benefit for VA-based researchers and promote collaboration with their UCSF colleagues. This is currently being considered.

I’m grateful to Ken McQuaid for his leadership and advocacy during these uncertain times.

Fresno

After 14 years as an outstanding chief of medicine at UCSF Fresno, Mike Peterson, now Associate Dean for UCSF Fresno, is passing on the torch for his role as chief of service. We have launched a search for an individual who can advance the work in Fresno and nurture the partnership with UCSF. The growing importance of large healthcare networks, data sharing, and telemedicine provides new opportunities for our SF-based programs to work more closely with our Fresno colleagues.

Research

Our department continues to lead the nation in NIH grants, with an amazing breadth of research activity that ranges from basic mechanisms to health policy. The most common complaint I hear from our researchers is about our clinical trials infrastructure. Led by the CTSI, there are changes in the works that should lead to major improvements in this area in 2017.

In addition to the physical spaces for research being considered at the VA and ZSFG, last year saw a consensus that we needed to revitalize both Parnassus and Mt. Zion. Mission Bay has proven to be a huge success, particularly for our basic research faculty and for those involved in UCSF-industry partnerships. An unintended consequence is that, by comparison, both Parnassus and Mt. Zion seem shabby and rudderless. The time has come to begin building exciting new programs and facilities at both Parnassus and MZ. Luckily, this is likely to be a key theme in an upcoming UCSF Campaign, and our department will have a powerful role in shaping these discussions.

Speaking of research and philanthropy, last year was remarkable. UCSF was the fourth leading recipient of philanthropic dollars among all U.S. universities – trailing only Harvard, Stanford, and USC. And we don’t have an undergraduate campus, a business school, or a football team! Major gifts include the ones that funded the Chan Zuckerberg BioHub, the Parker Institute for Cancer Immunotherapy, the Weill Institute for Neurosciences, and $50M from the late Bill Bowes to support young investigators. And just today came the announcement of a new gift of $500M, the largest in UCSF's history, from the Helen Diller Foundation to support our people and programs. On top of that, there have been many other gifts that have supported specific faculty and programs in the DOM.

We will soon select our two Associate Chairs for Research: one for Clinical and the other for Biomedical. Indeed, it takes two people to fill the very large shoes of the retiring Bill Seaman! We had an outstanding applicant pool, and I should be able to announce these selections in the next 8 weeks.

Education

Perhaps the biggest news in education was the launching of the Bridges curriculum for our students, which went well, in part because of major leadership by DOM faculty, including our Associate Chair for Education (and Stanford Sports Hall of Famer [for golf]) Pat Cornett. We are gearing up for our residency match – the applicant pool is outstanding. This year we emphasized both diversity and academic potential in our screening, and the pool reflects that. The recent fellows match was fantastic, one of our best ever for many of our divisions. While the funding model for education remains challenging, this may well be our most stable "line of business."

People

The troubling data from the 2015 faculty and staff engagement surveys (low "net promoter scores") have energized campus leaders, including in our department, to understand the sources of dissatisfaction and address them. Some, like the cost of housing, are beyond our control, although we are doing what we can to improve salaries. Others that relate to culture and community, or to obstacles that prevent people from doing their best work, are more tractable, and we are doing what we can to tackle them. On top of that, we have made a major commitment to improve diversity, and I am grateful to the members of the DOM Diversity Task Force, which made a number of thoughtful recommendations that we are currently acting on.

As I announced earlier this week, Beth Harleman will take on a new role of Associate Chair for Faculty Experience – helping to lead our efforts in recruiting, onboarding, retention, leadership, building community, and improving culture. Working with a new Director for Faculty Diversity (search to be launched later this year) and Sarah Schaeffer (who leads our Residency Diversity Committee), Beth will also oversee our efforts in diversity.

On the staff side, we will recruit a Staff Experience Specialist, reporting to the Associate Chair for Administration, who will help develop programs to enhance staff engagement and development. Speaking of the Associate Chair for Administration, I should be able to announce a permanent choice for this role, as well as for the role of Associate Chair for Finance, in the next few weeks.

Other Cross-cutting Issues

Many of our toughest and most interesting issues are ones that cut across multiple divisions, sites, and specialties. They include:

Cross-divisional collaboration and structure: Our three independent division structure has served us very well for decades. Yet it is clear that some of our divisions collaborate across sites beautifully; others not so much. I’d like to examine this issue, and see what we can do to promote better cross-site collaboration. It is also worth taking a look at the overall divisional structure. We currently have two multi-site divisions (geriatrics and occupational medicine) and we may even consider trying to extend this experiment when it makes sense (for example, when two of the three chief positions are open). We will go very slowly here, making sure to talk through any change carefully and do our best to consider all the consequences.

We will have a DOM Leadership retreat later this month, and the topic of cross-site collaboration will be the theme. Bill Bremner, chair of medicine at the University of Washington (a program that is very similar to ours [university, VA, and county hospitals] yet uses a different divisional structure) will address the group of Associate and Vice Chairs, Division Chiefs, Division Managers, and other department leaders to start what should be an important conversation.

Cross-cutting specialties: Examples here include medical genetics (when Bob Nussbaum left for industry, we shut down our very small division of medical genetics, but now we need to decide on a strategy going forward), palliative care (which currently has a substantial presence in at least three different divisions), and informatics (which is becoming near ubiquitous). In each of these areas, we will be taking a good look at the current structure and thinking about whether it can be improved upon.

Speaking of informatics, this is the area that, I believe, has the greatest potential to utterly transform everything we do. I want our department to be the national leader in informatics; I’ve become convinced that no organization will be great in the future if it’s not great in using technology to deliver value. And, given our location, it would be a lost opportunity for us not to take advantage of our proximity to Silicon Valley. You can expect some exciting announcements about new programs, people, and partnerships in this area in the coming weeks and months.

As you can see, I can’t help but to be bullish about 2017, at least as it pertains to our department. Washington… we’ll see.

Thanks for all you do for our department and for UCSF, and best wishes for a great year for you, both personally and professionally.

 

Robert Wachter, MD
Chair, Department of Medicine